3. Lecture 2 Physiologic change during pregnancy อ.วรพงษ์

เอกสารประกอบการเรียน พล.ต. วรพงษ์ คงมีผล Physiologic change during pregnancy “Maternal adaptation to pregnancy” พล.ต. วรพงษ์ คงมผี ล กองสตู นิ รีเวชกรรม รพ.พระมงกุฏเกล้าAim : Students can describe characteristic and changing of important systems to pregnancyI. Reproductive system 5.4. Hypervascularization , striaeChangings : 5.5. Colostrum 1. Vulva & Vagina : Bluish discolorization , II. Abdominal wall and skin Chadwick’s sign 1. Striae gravidarum 2. Diastasis recti 2. Cervix: Hypertrophy & Hyperplasia , 3. Pigmentation : Linea nigra , Chloasma or Bluish discolorization Melasma gravidarum Softening : Goodell’s sign Short & Thin : Early labor III. Cutaneous vascular changes : 1. Angiomas , Vascular spiders 3. Uterus 2. Palmar erythema – Hyperestrogenemia 3.1. Hypertrophy & Dilatation 3.2. Size , shape & position IV. Metabolic change 3.3. Hypervascularization 1. Weight gain 3.4. Uteroplacental blood flow Maternal reserves 3.5. Decidualization average 12.5 kg. , 80,000 kcal. 3.6. Uterine contraction 2. Water metabolism 3.6.1 Braxton Hicks contraction average extrawater 6.5 L. 3.6.2 False Labor plasma osmolarity fall 10 mosm/kg. 3. Protein metabolism 4. Ovary Increasing daily requirement 4.1. No ovulation At term Fetus & Placenta protein weigh 4.2. Decidual reaction 500 gm. 4.3. Corpus Luteum of pregnancy : 4. Carbohydrate metabolism Progesterone, Relaxin D.M. may appear only during pregnancy 4.4. Pregnancy Luteoma & 5. Fat metabolism Hyperreactioluteinalis Plasma lipid ↑ throughout gestation LDL – Cholesterol levels peak at wk. 36 5. Breast HDL – Cholesterol peak at GA 25 wk., 5.1. Nipple : Dark discolorization , ↓until GA 32 wk. Enlarge & Erection 5.2. Areolar : Montgomery’s Tubercle 5.3. Mammary glands & Duct increasing

6. Mineral metabolism VI. Cardiovascular System Requirement for Iron is often exceed , 1. Heart but most other minerals are little change - Left & upward displaced - Pulse rate ↑10 – 15 min. 7. Acid – Base Equilibrium - Splitting first sound Normally pregnant hyperventilates - Murmur : Systolic , Diastolic & Continuouscauses respiratory alkalosis by lowering pCO2 2. Cardiac output Appears to impair release of O2 from - ↑most during second stage of labor 3. Circulationmaternal blood to fetus - Supine Hypotension 8. Plasma Electrolytes  Supine hypotensive syndrome Large accumulation of Na & K.  Supine pressor test Serum concentration of Na & K. ↓ - Blood flow to skin but Na & K. excretion are unchanged VII.Respiratory tractV. Hematological change 1. Anatomical changes 1. Blood volume: At near term ↑average 40 – - Diaphragm elevates 4 cm. 45% both plasma & RBC , but plasma more - Thoracic circumference increases 6 cm. than RBC 2. Pulmonary function 2. RBC volume ↑av. 450 ml. or 33% - Physiological dyspnea 3. Hemoglobin concentration and Hematocrit - ↑oxygen requirement when supine - Erythropoiesis is augmented , but Hct. VIII. Urinary System↓esp. late pregnancy. Iron deficiency rather 1. Kidneythan to hypervolemia - Size ↑1.5 cm. longer during early puerperium than when measured 4. Iron metabolism 6 mo. later - Iron storage : 2 – 2.5 gm. Normal adult - GFR & RPF ↑but RPF ↓during late women pregnancy - Iron requirement : Total 1,000 mg. (daily - Posture affects sodium & water excretion requirement 6 – 7 mg. ) in late pregnancy - Blood loss : 500 – 600 ml. during & after 2. Loss of nutrients: Lost of amino acids & vaginal delivery water soluble vitamins 3. Urinalysis 5. Leukocyte functions - Glucosuria , Proteinuria & Hematuria - Usually ranges 5,000 – 12,000 ml. - During labor & puerperium may be elevated to 25,000 ml. 6. Blood coagulation - ↑plasma factors : 1 , 7 , 8 , 9 , 10 - ↓plasma factors : 11 , 13

4. Hydronephrosis and Hydroureter 5. Thyroid gland Cause : Hormonal & Compression effect - Moderate enlargement - Thyroxin & protein bound iodine (PBI) ↑ 5. Bladder - Thyroxin binding globulin ↑so much , - Urinary incontinence result of Estrogen - Iodine level ↓IX. Gastrointestinal Tract - Displacement of Stomach , Intestines & 6. Adrenal glands Appendix - Little morphological change - Delayed gastric emptying time - Cortisol - Pyrosis ( Heartburn )  considerable ↑but bound by - Epulis cortisol-binding globulin , trancortin - Hemorrhoids  ↓secretion , but excretion is slower 1. Liver - ACTH - Alkaline phosphatase ↑double  ↓in early pregnancy - Plasma albumin ↓, globulin ↑  ↑in late pregnancy - Cholinesterase ↓ - Aldosterone – at 15 wk. pregnancy ↑by third trimester about 1 mg/day to 2. Gallbladder prevent loss of sodium - Impaired contraction & high residual volume XI. Musculoskeleton system - ↑cholesterol saturation , stones - Progressive lordosis , anterior flexion of neck & slumping of shoulder girdleX. Endocrine System produce traction on Ulnar & Median 1. Pituitary gland nerves - Enlarges to compress optic chiasma & - ↑mobility of Sacroiliac , minimal reduce visual fields Sacrococcygeal and pubic joints 2. Growth Hormone - Slight ↑in first trimester , but HPL is XII. Eyes abundant - ↓intraocular pressure , Corneal 3. Prolactin sensitivity - ↑to 10 – fold at Term - ↑corneal thickness to be due to edema 4. Parathyroid glands - Visual function is unaffected - Physiological hyperparathyroidism to supply fetus with adequate calcium XIII. Psychological system - Anxiety - Depression